Attachment For Report Of Independent Med Exam Scheduled Loss Of Use {IME-4.3A}

PO Box 5205 Binghamton, NY 13902-5205Customer Service Toll-Free Line: (877) 632-4996 Statewide Fax Line: (877) 533-0337 www.wcb.ny.gov ATTACHMENT FOR REPORT OF INDEPENDENT MEDICAL EXAMINATION SCHEDULED LOSS OF USEPlease utilize this form as an attachment to the IME report, where there is an injury to a scheduled body part. These attachments will be considered part of the IME report, and must be served together with the IME-4. Claimant's Name (LAST, FIRST, MI): Social Security No.: WCB Case No.: Date of Injury/Illness: Date of Examination:A. Permanent Partial Disability If the claimant has a permanent partial impairment, complete A1 for all body parts and conditions for which a schedule award is appropriate (schedule loss of use). Use Form IME-4.3B for all body parts and conditions for which a non-schedule award (classification) is appropriate. A1. Schedule Loss of Use of Member:Body Part Please include all the information in the bullet points below in the table on this page or attach a medical narrative with your report. The medical narrative should include the following information: l Affected body part (include left or right side) and identify Guideline chapter (when special consideration exist). l Measured Active Range of Motion (ROM) (3 measurements for injured body part, and use the greatest ROM. If not, please explain why. l Measurement of contralateral body part ROM, or explain why inapplicable l Previously received scheduled losses of use to same body part(s), if known l Special considerations l Loading for Digits and Toes Details:IME-4.3A (5-18) Page 1 Body Part/Measurement 1 Left Right Body Part/Measurement 2 Left Right Body Part/Measurement 3 Left Right Body Part/Measurement 4 Left Right Body Part/Measurement 5 Left Right Body Part/Measurement 6 Left Right Range of Motion (3 measures) Contralateral ROM Contralateral Applicable Y/N If No, please explain below Special Considerations (Chapter) Impairment % American LegalNet, Inc. www.FormsWorkFlow.com